The language of pain

Have you ever wondered about the ways we communicate our pain? Pain behaviour doesn’t just include nonverbal communication – one of the main ways we communicate our pain is through speech. Words are an incredibly powerful aspect of pain behaviour that strikes me as something we haven’t really studied much. When I was searching for the article to refer to in this post, I looked in PsychInfo under the terms “linguistics” and “pain” – and out of the tens of thousands of articles under each term, and total of 16 included both words. Sixteen!

The stimulus for this post comes from someone who said the term “catastrophising” is a misnomer – a way for health professionals to dismiss or minimise the suffering and distress someone who has pain is experiencing. In this person’s words “Now its no longer just a buzzword but a label that pain docs like to attach to everyone in chronic pain who indicates they are suffering. And of course as most pain docs dont particularly care for hearing about suffering of those in pain they then attempt to get them to go for some cbt or psychotropics.”

Now, I preface this next section with the notice that I’m no linguist (although it’s something I’d love to learn about!). But in a paper by Elena Semino, it’s absolutely fascinating to read about the ways in which people describe pain – she starts by saying “sensations conveyed by the English word pain tend to be described via expressions that refer to potential causes of bodily damage.” Note the word “causes”. She gives the example of someone describing their pain as “sharp“, “like a rake over my eyes and head, digging in and scraping away”, noting that “expressions such as “sharp pain” function metonymically when they describe pain that directly results from physical damage, and metaphorically when no such damage is involved”. (BTW Metonyms are figures of speech that replace a word with a word that is intimately associated with that thing or concept. For example, in New Zealand “the Beehive” refers to Parliament, because that is the name of the building in which Parliament is housed.)

The reason we use terms like “sharp” or “stabbing”, argues Semino, is that “that these uses of metaphor may facilitate some form of internal embodied simulation of pain experiences on the part of listeners/readers, which may in turn provide the basis for an empathic response.”

Pain behaviour of all types functions in the same way – evolutionary psychologists suggest that they are remnants of early signalling behaviour designed to elicit a response from those around the individual. It makes sense that if a group of prehistoric people are hunting, someone who has pain can signal to others through crying or groaning that “something’s wrong”, hopefully eliciting some sort of caring behaviour from the rest of the troup, with the withdrawal response later helping the individual remain still and quiet in the back of the cave so as to minimise the potential for sabretooth snacking!

What Semino and others postulate is that the language we use when describing pain draws upon the neurophysiological aspects of shared experience or empathy – the “mirror neurones”. fMRI studies of the anterior cingulate cortex, the bilateral anterior insula, rostral anterior cingulate cortex and the sensorimotor areas of the neuromatrix (aka “pain” matrix – but this is probably a misnomer) show these are activated when individuals observe another person experiencing a painful procedure or hear words describing these procedures.

Semino quotes Avenanti et al., (2005) who suggests that there are “two forms of empathy linked to one another in an evolutionary and developmental perspective. A comparatively simple form of empathy, based on somatic resonance, may be primarily concerned with mapping external stimuli onto one’s body. A more complex form of empathy, based on affective resonance, may deal with emotional sharing and with the evaluation of social bonds and interpersonal relations. p.958”.

Semino therefore proposes that metaphorical descriptions of pain that allude to causes of physical damage may trigger embodied simulations of similar experiences – and that both types of empathy are enacted when we use descriptive metaphors when talking about pain.

OK, where does this leave us when thinking about “catastrophising”? Catastrophising is the tendency to “think the worst” in a situation. An example might be saying “my headache is killing me”. Catastrophising influences an individuals appraisal of their situation. Although this way of describing their situation does convey an individuals level of distress, catastrophic interpretations actually impede effective problem solving and active coping. Catastrophising is associated with increased disability, high distress, low mood and high helplessness.

Is it normal to catastrophise? At times, yes. Most of us will do a little catastrophising from time to time, if we’re honest with ourselves. But even if it’s normal, catastrophising isn’t helpful. Again, most of us will catastrophise for a short while, then change our thinking and begin to speak differently and approach our situation differently – usually with a view to taking steps to exert some level of control over our situation.

I think it’s important to consider our use of language as health professionals, and it’s one reason for thinking about how we write reports, for example. While we have our own technical language and use it amongst ourselves (and the term catastrophising is one of them) we need to be aware that people who don’t know the meaning of these terms can misconstrue them. And in the case of some patients, feel misunderstood and sometimes offended. We need to think about this and avoid using jargon where practicable.

More importantly, we need to be incredibly careful not to use terms in a pejorative or dismissive way. We’ve moved a long way from describing a woman with pain as being “hysterical” – but terms like “functional pain” or “supratentorial” or “malingering” can still be found in some reports.

I think the best thing we can do when we’ve been talking with someone who does “catastrophise” is make it clear that we are not dismissing their pain as less than what they say it is, but instead to be sensitive to their language and reflect that their pain is very distressing and difficult to deal with. Because in the end, that’s what the language used when sone tends to catastrophise is intended to elicit from us.

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10 comments

Linguistics is my specialty. And there are so many problems in this post, I don’t even know where to begin… Let me point out what I think is the biggest problem. I’ll quote a well-respected metaphor project carried out at the University of Leeds: “it is over-simplistic to assume, as happens in some research studies, that elicited or spontaneously produced linguistic metaphors are evidence for individually-held conceptual metaphors i.e. that what is said directly reflects what is thought”.

To bring it back to your post, someone who says “my back is killing me” is employing a metaphor; it does not mean that they think they are dying. It does not mean they are catastrophising, either. They are using language in a dramatic way, yes. But it has little in common with your valid catastrophising examples from yesterday, such as “The doctor said I will end up in a wheelchair”. The latter is a direct expression of the actual belief, and indeed evidence of strong negative thinking; the other is just expressive language that is influenced by a whole host of factors, and does not necessarily reflect what the person actually thinks.

Then again metaphors for feelings of pain… That theory started right: metaphorical expressions like “stabbing” came into existence because people who used them were making some connections with potential causes of pain. That’s how all metaphors work: we need to describe something abstract, we relate it to something concrete in the physical world that other people can understand more easily. But it does not mean, in any way, that a person using the word “stabbing” attributes any specific cause to it. No more than anyone who talks about “rising prises” is associating any physical cause with the word “rise”, even though this metaphor originated in some notion of a physical increase in size.

So I would agree with your reader – if you read too much into metaphorical usages like “stabbing pain”, or even “pain is killing me”, you come across as assigning labels, and not willing to hear about someone’s distress, and not allowing someone to express their feelings in a natural way. Metaphors do matter, and they say something about how people think, but it is nowhere near as straightforward as the research you quote implies, and a lot more evidence is necessary before you can use it this way.

Mary, while I totally respect your linguistics background, I think it’s really important to reflect on at least two things: firstly, the author of this paper was integrating linguistics research, fMRI studies on the effects of verbal utterances, and psychological studies on the associations between verbal utterances and both emotional distress and disability; secondly I certainly appreciate that people who say things like “my pain is killing me” don’t actually believe that they will die from their pain. As I point out, it’s important to listen to and reflect back to the person saying these things that they are feeling very distressed by their pain and finding it difficult to cope.

The point of this post was to indicate that there is a direct relationship between the words that people use to describe their pain and activity in various parts of the brain that are associated with the experience of pain – both in the individual saying them, and in the listener. This is a profound finding, because it can explain why clinicians (a) can become burned out when working in this field and (b) can use strategies like depersonalising and ‘switching off’ or distancing themselves from the emotional intensity communicated to them by people who are distressed. In other words, it can explain some of the neurobiological processes involved. It can also help to explain the negative effect of using metaphors like “my pain is killing me” because they seem to activate the areas of the brain involved in negative emotions – this is exhausting for individuals who are already fatigued by their pain, as well as activating areas of the brain associated with physiological arousal (the release of “stress hormones”), and restricts the range of active coping the person can engage in.

Psychological research consistently demonstrates that by learning to “tune down” the language people use, the emotional distress and disability are reduced.

It’s a bit of a balance when listening to people who have chronic pain. On the one hand, clinicians want to be empathic and recognise the anguish that some people experience as a result of their pain, but on the other hand, clinicians also want to help people do things differently so they can achieve a different result. So I think it’s a process of first listening, then reflecting (with empathy), and finally helping the person develop new and different ways of viewing their situation so that they can cope more effectively.

[… It can also help to explain the negative effect of using metaphors like “my pain is killing me” because they seem to activate the areas of the brain involved in negative emotions – this is exhausting for individuals who are already fatigued by their pain, as well as activating areas of the brain associated with physiological arousal (the release of “stress hormones”), and restricts the range of active coping the person can engage in. …]

And that is exactly the problem – I would argue that this is a dangerous overinterpretation of results, at least given what I have seen/read in various literature. Of course, I don’t have the full grasp of psychological literature, so there may be pieces of research that I am unaware

The claim of Semino is straightforward: descriptions of pain activate “embodied simulation” and therefore may explain empathic response.

Then there is the claim “catastrophising is a specific technical medical term, describing symptoms that are associated with disability”. True again, but this is as long as you are talking about catastrophising appropriately measured by questionnaires. If I remember those correctly, they try to elicit directly what the person feels: “I feel I can’t go on”, “There is nothing that can help me” and so on. These are pretty direct evidence of beliefs, and yes, it is a strong (and unsurprising) result that it is related to disability.

But then you move on to link these two by saying that the words we use stimulate our brain and suddenly the use of metaphors becomes bad/dangerous/ineffective. This is where it becomes really problematic. I unfortunately don’t have access to the full article text, but on the limited information in the abstract, the features that stimulate stronger responses are linguistic creativity, level of detail and textual complexity – which would mean new and interesting descriptions like “the rake in my eyes” and not the conventional words like “stabbing”, or “killing”, or whatever.

You need to prove such links with evidence – i.e., collect sufficient number of transcripts of what people say in interviews/diaries, get an annotation scheme together that identifies negative metaphors, ensure that your have sufficiently high reliability between raters identifying those (not an easy task!), and then show that this is correlated with either catastrophising scores, or with actual disability outcome. Or else you would have to have a medical study showing indeed that the use of such words increases pain, distress, stress hormones, whatever.

Maybe such studies exist, and then indeed I am wrong. But FMRI areas “lighting up” is really not enough evidence for making links like that.

And I would even say that it makes sense that constant use of strong negative metaphors is common sense evidence of catastrophising. But I think this is a very dangerous line that you choose for your examples some pretty common, typical expressions, rather than the more extravagant expressions (of which I see plenty on various patient messaging boards). In picking on the use of expressions common in everyday speech and linking it with catastrophising is where, in my opinion, catastrophising stops being a specialized medical term and starts being a label, causing reactions like you heard from that person which prompted your post.

Just so I’m sure I interpret what you’ve said accurately, here’s my summary of your concern with this post and my comment:
– you’re worried that I’m over-stating the relationship between metaphoric language and catastrophising
– you’re concerned that examples of statements like “my pain is killing me” are milder than those quoted in the article and as a result I’m drawing conclusions that are inaccurate
– you’re not certain whether there is a relationship between what people say and disability or catastrophising
– you’re not sure whether fMRI findings quoted in this paper and the use of metaphoric language is evidence of a link between language and distress/disability
– you are not sure that it’s possible to identify catastrophising from verbalisations instead of using questionnaires

Can you let me know if I’ve understood you correctly before I respond?
Thanks
Bronnie

Did I sound distressed? I was having a bad day😉 But what you said is mostly true with respect to what I believe:

– I think that you are over-stating the relationship between metaphoric language and catastrophising, in context of the actual research that you quote
– I think that examples of statements like “my pain is killing me” are “conventionalized” everyday usage, frequently found in the way people talk, and therefore inappropriate to draw conclusions about the person’s belief or mental state
– I think that there is a relationship between what people say and disability or catastrophising, but it cannot be judged based on the “surface”. There is a huge body of research on “sentiment analysis”, trying to have automatic methods of judging peoples attitudes, and this is one of its main outcomes: the same words can be positive, negative and neutral, depending on the wider context. I am worried that the examples like you give are largely too decontextualized, and in effect use expressions that are not indicative of much.
– I am not sure whether fMRI findings quoted in this paper and the use of metaphoric language is evidence of a link between language and distress/disability
– I think it should be possible to identify catastrophising from the general way people talk even if they are not expressing beliefs directly like they do in questionnaires, but this is a non-straightforward task that requires proper statistics done on large bodies of relevant interview transcripts (which is the proper method for linguistic studies), which would take into account natural variation and conventional usages, and not on analysis of individual examples.

I guess examples that are shown are my specific worry, because I have encountered more than once doctors who seem to listen to “keywords”, based on such general examples. So CBT, which is a well-founded scientific method, and supported by well-devised evidence, gets reduced to this much more surfacy approach that gets more harm than good.

1. Some people may use certain terms to speak dramatically, as Mary pointed out. Language is like a 64 pack of crayons. Some people will stick to the primary colours when they speak and others will use all 64, and then some. I think the same holds true when people are describing their pain.

2. I had an interesting experience when I was doing a demo. (Forgive me if I’ve mentioned it here, before.) I was explaining to a woman how thoughts and emotions affect one’s heart rate variability, when I made the comment that the information that she could think of this information as a vaccine against stress. Immediately, her heart rate went way up, and her breathing and posture changed. As you can guess, it was the word “vaccine” that did it. She was terrified of needles. We can’t possibly know what triggers people’s stress, but it is helpful to understand that such things do occur.

3. One thing I’ve learned to do in my own journey to wellness is to be very specific in the language I use when I describe my pain. For obvious reasons I no longer say things like “I feel old” or “that’s killing me”. Perhaps my speech is a little more boring, since the dramatic is now eliminated, but I can live (very well) with that!🙂

Thanks for your thoughts! I agree that people differ in the language they use to describe things – some men use the term “pink” for every colour ranging between peach and salmon! The interesting thing to consider is the effect on both the individual using those words (in terms of the emotional content and parts of the brain that become involved), and the effect on other people – both the neurological effect on the brain (mirror neurones and others) as well as the social. After all, language is about communicating.
That’s an interesting description of the effect of a word (with all the associated learning) on heart rate, breathing, posture and so on – and these things are driven from the brain or they wouldn’t occur! – so if you had fMRI of that woman’s brain when you said the word “needle”, I assume that many parts of her brain would “light up”, or in other words, become activated.
Like you, I’ve become more focused on the specific words I use to describe the sensations I experience. While the pain I have may be no different, the effect of my not using metaphor like “my back is being squeezed by giant hands” or “I have a huge clamp around my head” on other people means they treat me more normally and I feel less disabled.
More on catastrophising this week!